OutREACH: eHealth Africa, Clinic Collaborate to Tackle Non-Communicable Diseases

by Moshood Isah

Hypertension is a major public health problem in Nigeria, with prevalence of 37.5%. This means that nearly 4 out of 10 Nigerian adults have hypertension. Similarly the prevalence of diabetes is increasing worldwide, and Nigeria is no exception; an estimated 7% of adults in Nigeria have diabetes, making it among the most common cardiovascular diseases in the country.

Unfortunately,  lack of access to quality and affordable hypertension and diabetes services in rural communities and primary health care is a major concern. This is largely due to  disparity in access to quality healthcare, especially between rural and urban areas in Nigeria as a result of  economic, social, geographic, and health workforce factors. For instance, the secondary health facilities where the few drugs are, with the facility for testing and the medical professionals are far from the rural communities, making access difficult. This is exacerbated by the high cost of medications, making it difficult for some clients to afford the treatment they need, resulting in low treatment outcomes.

Thus, adapting and digitizing  the World Health Organisation Package of Essential Noncommunicable (PEN) disease interventions for primary health care, eHealth Africa is collaborating with the EHA Clinic Reaching Everyone with Accessible Community Healthcare (REACH) program to reach out to marginalized communities with healthcare interventions. This, according to the Project Manager Lucy Okoye, is aimed at improving access to quality care and affordable services for persons with hypertension and diabetes and others at risk. 

She said, “Social mobilization activities will increase rural communities' knowledge of hypertension and diabetes”, saying  the identification of risk factors and the signs of hypertension and diabetes will likely result in the adoption of a preventive healthy lifestyle and prompt seeking of treatment. Another potential impact of the intervention according to her is to reduce the prevalence of hypertension and diabetes and improve the health and well-being of the target communities, helping people to live longer and lead healthier lives. 

In February, eHealth Africa supported the free medical outreach conducted in the Kuje community of the Federal Capital Territory and Gyadi-Gyadi community of Kano state. According to Adawiya, Mahmud Ila, Product and Quality Assurance Coordinator at the EHA REACH clinic said the outreach is an opportunity to reach the people accessible and  to provide free healthcare within the community. 

“We are having an outreach where we see hypertension and diabetic patients,we measure the blood pressure and fasten blood sugar.”  If there is a need for us to give hypertensive and glycine medication we give them which is going to be free for 6 months”, she said.

She said, the economic realities in developing countries like Nigeria limits citizens especially the older generation from accessing good medical care.  She said, “You know how the economy is in Nigeria; economically it's hard for them to go to the hospital so we are just trying to make an impact in the community”.

Speaking on community acceptance and mobilization strategy for the outreach, Adawiya said, the partners leveraged on its Community Health Extension Workers (CHEW) to discuss the impact of the intervention  with traditional leaders and community influencers. 

Community Feedback

Zainab Abdullahi is  a resident of Kasuwan Dare area of Gyadi-Gyadi community of Kano state. She heard of the REACH Clinic Outreach through community influencers. “Now they checked our BP,Blood sugar level and from here we will proceed to see the doctor”, she said. 

Zainab lauded the outreach initiative saying the community is receptive to ideas like this. “the hospital environment is clean and welcoming and this is why you can see close to 100 people coming for this outreach”.  “If they can spread their tentacles and establish  this kind of hospital in all areas, we will be happy so that everyone will visit the nearest hospital rather than going far from home to access healthcare”, she said.  There is also a need to have additional doctors to attend to a growing number of patients in a bid to reduce waiting time, she said.

Ahmed Salisu Musa has spent 45 years in the community.  He expressed his excitement saying the outreach has brought good healthcare delivery to his doorstep. “They took my blood samples, gave me some medications and I was told, I am not diabetic”, he said

He said, “as a community leader myself, I am glad to  have witnessed what is happening and will pull  in more people to come and get checked.” Musa called for increased mobilization of citizens and more importantly expansion of the intervention to reach other communities.

Nasarawa SPHCDB set to Sustain Vaccination Progress with User-Friendly EMID Mobile App

by Moshood Isah

The race to  ensure accessibility to  COVID-19 Vaccine and  intensive campaigns to promote the uptake of the vaccines led to its routinization especially in developing countries.   To further ensure the successful implementation of its COVID-19 vaccine deployment plan and address existing challenges of data management, Nigeria developed the Electronic Management of Immunization Data (EMID) system in 2021. By the end of the year,  the National Primary Health Care Development Agency (NPHCDA) revealed that Nasarawa state, located in North Central part of Nigeria has again overtaken other states in the COVID-19 mass vaccination campaign in Nigeria.

However, recent experience has also revealed that manual data collection remains vulnerable to damage or manipulation. Digital solutions remain mostly more recommended as it enables more accurate data capturing and better storage process.  However, the potential challenges that could hamper the progress of development and utilization of digital solutions for management of immunization data are likely technical glitches and capacity limitations of health officials, especially in underserved communities. 

 To Address these challenges, eHealth Africa in partnership with National Primary Health Care Development Agency supported by GAVI developed an optimized version of the EMID mobile application, incorporating routine immunization to further standardize and harmonize data collection and storage. Thus, eHA successfully completed the training of healthcare personnel across the country, in the use of the EMID Native App.

Speaking during the training session for healthcare personnel and immunization recorders across over 300 Primary Health facilities in Nasarawa state, key stakeholders highlighted how the optimum utilization of the EMID application will sustain vaccination progress in the state.

LGA EMID Focal Persons in Nasarawa state after a Training of Trainers on optimised EMID application

Abubakar Alilu Awei, State Primary Healthcare Development Board, (SPHCDB) Immunization Officer (SIO) said the presence of EMID Focal persons at the LGAs ensuring that all recorders upload information of clients on the national server was indeed instrumental in the state progress during the COVID 19 vaccination.  He said, “You may recall that Nasarawa state emerged as the overall best performing state in Nigeria in terms of COVID-19 vaccination and also the best performing state in the North central zone. This may not be unconnected to the good use of our EMID application that we adopted during the COVID 19 vaccination.”

Awei further lauded the incorporation of routine immunization into the application saying, the training is timely as it  will enable the state to have  data on the server to enable adequate tracking of client information. He said, “with the optimized EMID app,  at a glance we can  check on the client that has been vaccinated with the first antigens. So when they come back to the health facilities for the next antigen it's just for the recorder at the health facility to go to the server and update the current antigens that they have received”. It reinforces the prospects for effective management of immunization data.

In a similar vein, Beatrice Samuel, NPHCDA, Zonal technical officer,  Nasarawa state said, “one of the things we really enjoyed is that we could see the accessibility, the user friendly and not much challenge”. While describing the optimization of the EMID app as a milestone for the agency and eHealth Africa, she called for its sustainability. 

“I  want to believe that the excitement we have now would not just go away. It should be something that will not give us challenges when we go to the field.  There should be a sustainable native app for us to enjoy more and more”.

Immunization Recorder in Doma LGA of Nasarawa State

In his words, Ahmed Ibrahim, EMID State Focal Person for Nasarawa State lauded eHealth Africa for leading the optimization of the application saying, “ our recorders at the health facility will now know the value and importance of keeping record”. He said the application guarantees the safety of data in its electronic form saying,  “even if the facility is burnt you can still go to the database and search for the record of any person”, he concluded. 

ehealth Africa Commits to promoting early detection of Vaccine Derived Polio Virus through Lab Support

by Moshood Isah

Nigeria may have been declared a polio free nation but the Variant Poliovirus Type 2 strain transmission still lingers. Nigeria reported 168 cases in 2022. This  has made further interventions crucial particularly  around early detection. The growing cases in a  number of African countries require a focused effort to strengthen polio laboratories that can effectively help the affected countries to quickly confirm cVDPV2 cases and launch outbreak responses, including the introduction of novel OPV2.  

In 2018, the World Health Organisation (WHO) introduced a Global Polio Surveillance Action Plan (GPSAP 2018-2020) to support endemic, outbreak, and high-risk countries in evaluating and increasing the sensitivity of their surveillance systems against Polio. The plan also initiated supplemental strategies that may help in closing gaps in detecting polioviruses, including strategies for immunodeficiency-associated vaccine-derived polioviruses (iVDPVs) while also strengthening coordination across surveillance field teams to foster a more effective programme and document zero cases worldwide. 

The new Global Polio Surveillance Action Plan (GPSAP) for 2022-2024. also focuses on increasing the speed of poliovirus detection, improving surveillance quality at the subnational level, fostering the integration of polio surveillance with surveillance for other epidemic-prone vaccine preventable diseases (VPDs), and mainstreaming gender equality in surveillance activities and programming as a key enabling factor.

To achieve parts of the Global Polio Surveillance Action Plan (GPSAP) 2022-2024, ehealth Africa worked with World Health Organisation (WHO)  supported by the Bill and Melinda Gates Foundation (BMGF) to  renovate and upgrade the   Sequencing Laboratory in the Virology department, University College Hospital (UCH) Ibadan, Oyo State. The laboratory was commissioned by Kazadi Walter, Country Representative and Head of Mission; World Health Organisation to Nigeria. This is part of the effort to improve surveillance, rapid detection and response against the spread of Vaccine Derived Polio Virus and other vaccine preventable diseases.  

Speaking during the official commissioning of the Laboratory, Dr. Kazadi Walter reiterated the commitment of WHO towards eradicating polio virus through the provision of facilities and rendering of technical support to Nigeria’s health care. He stated that WHO in collaboration with the government established the Global Polio Laboratory Network of which 16 are currently in Africa, with two located in Nigeria; Ibadan and Maiduguri. According to Walter, the primary objective is to work with WHO in the African Region (AFRO) to equip the global polio laboratory network labs for robust and rapid sample analysis for polio and to provide support in equipping these labs with sequencing capabilities.

Prof. Kayode Adebowale, the university vice chancellor, commended the initiative saying “this laboratory will not only provide vital information for the eradication of polio but also contribute to our university infrastructure, helping us to fulfill our vision and mission in addressing social needs.” The VC said: “The department has played a crucial role in Nigeria’s polio eradication programmes by contributing significantly to the country’s achievements of being declared wild polio-free in 2021.

Speaking on the role of eHealth Africa in the support for Laboratory Supplies across selected countries in Africa, the Project Manager, Tolulope Oginni said, to ensure optimum utility of the laboratory supplies, eHealth Africa leverages previous and current experience in setting up and managing Emergency Operation Centers to strengthen the staff capacity at the Laboratories in operating the installed equipment.

“These interventions  for  the support for laboratory supply and installation with consumables currently ongoing in at least 12 African countries are expected to improve the labs functionality for faster outbreak detection”, he said. With the support of other stakeholders in the region, this intervention will support labs in the African region that are targeted for expansion of sequencing capacity, support to improve existing sequencing capacity, or labs that require support for virus isolation and identification. This intervention has a huge opportunity to explore collaboration with WHO and other global stakeholders to transform the laboratory infrastructure in Africa into world class facilities which in turn will significantly strengthen their capacity and preparedness for disease outbreaks.

Improving Emergency Response by Upgrading Information Technology Systems to Better Respond to COVID-19

By AbdulHamid Yahaya and Emerald Awa-Agwu

The Kano State Polio Emergency Operations Center

When designing technology and data solutions, we take the unique needs and contexts of our partners into account. We are then able to give them custom solutions that integrate seamlessly with their systems and that can be deployed easily to respond to active and potential public health emergencies. We provide operational support to Nigeria’s Polio Emergency Operations Centers (PEOCs). Initially designed to coordinate the country’s response to Polio, the EOCs now serve as a command center for decision-makers, program planners, and partners in the health space to plan and mount a coordinated response to all public health emergencies and outbreaks.

In Kano State, the EOC has been instrumental for Routine Immunization (RI) and Supplementary Immunization Activities (SIAs). The State Emergency Routine Immunization Coordination Center (SERICC) uses the well-equipped data infrastructure at the EOC to easily visualize health facility immunization data and immunization coverage data from campaigns on a weekly basis in order to monitor thresholds of priority infectious diseases. This helps them proactively identify patterns and trends in disease occurrence and respond more promptly to forestall outbreaks or epidemics.

On April 11, 2020, when Kano State recorded its first COVID-19 case, we quickly needed to upgrade the phone system so that the state EOC could better respond to the outbreak. Kano state needed a call center where community members could report cases and persons of interest could be followed up. While we set up the call center, we needed to switch the Private Branch Exchange (PBX) from Elastix 2.5 to 3CX. A PBX phone system is a private telephone network used within an organization that allows users to communicate internally (within their company) and externally (with the outside world), using different communication channels. It is ideal for call centers because it also allows for more calls than physical phone lines and free calls between users.

The Kano State COVID-19 call center

This became relevant because it shortened our turnaround time so that we could set up any additional support queues and lines faster. The upgrade also supported an unlimited number of agents to be added to the phone system at no additional cost and even allow agents to work remotely. This was vital for the response in Kano State to keep track of the large number of calls that they received and the persons of interest that were identified in a short time. 

The call center agents do not need to be in a physical location to operate the lines which aligned well with the state’s movement restrictions and social distancing guidelines. Our partners and stakeholders were still able to collaborate, discuss, and resolve issues quickly using the 3CX WebMeeting feature for video conferencing calls. The call center logs over 500 calls on a weekly basis.

Because of our experience with Kano state, we were also able to support Nigeria’s COVID-19 response led by the Nigeria Centre for Disease Control and Prevention (NCDC) by developing an automated system for tracking and following up persons of interest who have been exposed to COVID-19 for a period of 14 days. The system can call thousands of contacts on a daily basis to verify whether or not they have developed symptoms.

Members of our Helpdesk team monitoring the PBX system

Thanks to 3CX technology, we currently support more than 3,000 dashboard users across 12 states with the potential for an unlimited number. We believe that technology is the key to developing sustainable and scalable solutions that can strengthen health systems.

The Strides of Polio Vaccination in Hard to Reach Areas (HTRs) in Borno State

By John Momoh

As Nigeria marks 3 years and 10 months without a new wild poliovirus case, here is how the program has contributed to the Polio Eradication initiative in Borno State since 2016:

Inaccessibility to some settlements in  North East, Nigeria presents a great challenge to the immunization program in states like Adamawa, Borno, and Yobe states where the ongoing conflict is most severe. Health facilities in these states have been destroyed leading to a reduced number of eligible children being reached with Routine Immunization (RI) services. The mass displacement of people, migration from settlements, and insecurity have all hindered the planning and execution of Supplementary Immunization Activities (SIAs) such as Immunization Plus Days (IPDs) and Outbreak Response (OBR) campaigns in the region.

A child receives his vaccination at a settlement in Maiduguri, Borno state during an IPD campaign

In 2016, after a wild poliovirus outbreak in Borno, the  Borno State Primary Health Care Development Agency (BSPHCDA), in close collaboration with World Health Organization (WHO), the Bill and Melinda Gates Foundation (BMGF), U.S Centers for Disease Control and Prevention (CDC), United Nations Children’s Fund (UNICEF), eHealth Africa (eHA), Solina Health and other partners, launched the Reach Every Settlement (RES) and the Reaching Inaccessible Children (RIC) to access under-5 children in partially Hard to Reach (HTR) and HTR settlements respectively in order to interrupt the transmission of the virus.

Polio eradication partners at a working group meeting

eHealth Africa has been supporting the projects by leveraging our expertise in Geographic Information Systems, field operations, and logistics to collect and analyze geospatial data to aid near real-time monitoring of the program and decision-making by the state and relevant key stakeholders.

Tracking Unknown Settlements in Anambra State, Nigeria

Since 2012, eHealth Africa has been part of national and global polio eradication efforts. For the most part, our interventions and support have been deployed in Northern Nigeria. However, when two cases of circulating vaccine-derived poliovirus type 2 (cVDPV2) were reported in Anambra state early this year, our field operations team was deployed to conduct Vaccination tracking and hamlet buster activities for the first time in eastern Nigeria.

The exercise was conducted in nine high-risk Local Government Areas of Anambra State and the data obtained from the exercise, including habitation status, geocoordinates, and settlement names, were used to develop comprehensive microplans for an upcoming Outbreak Response (OBR) activity in the state. 

We appreciate the members of our Field Operations team who work long hours, travel to distant locations and brave difficult terrain to help us reach every last child with lifesaving vaccination services.

Click the slide show to see how the trip went.

You never know what will happen on the field, so we take everything we need

Field Officers getting ready for deployment

Sometimes the road is dusty

Sometimes, there is insane traffic

But we always move together

The terrain is never easy, so, no mode of transportation is off limits

Even canoes

It’s grueling work- The PFOs need to train LGA ward focal persons and supervisors before the commencement of the campaign

But there’s always time for a selfie

Using Geospatial Technology to Improve Vaccination Coverage Rates: A Case Study of Ganjuwa LGA, Bauchi State

By Fatima Mohammed

In May 2012, Nigeria and 193 other member states of the World Health Assembly endorsed the Global Vaccine Action Plan (GVAP), a strategy to launch the “Decade of Vaccines” during which millions of deaths would be prevented through more equitable access to vaccines, by 2020. Two important targets of this plan were that all 194 countries should attain a national coverage of 90% and 80% in every district or equivalent administrative unit, for all vaccines.

Since the launch of the plan, the National Program on Immunization (NPI) led by the National Primary Health Care Development Agency (NPHCDA), has made great efforts to increase the immunization coverage rate in Nigeria. Immunization is a top priority for decision-makers and they have collaborated with partner organizations to develop strategies to strengthen the delivery and demand for Routine Immunization (RI) and Supplementary Immunization Activities (SIAs). As a result, more children have been vaccinated than ever before1. However, Nigeria is still ranked as one of the countries with the lowest immunization coverage rates globally2. Several factors such as the insurgency in the Northeast, and cultural perceptions and beliefs leading to non-compliance and drop-out rates, have contributed to this but a major challenge has been the lack of an accurate denominator.

A child getting vaccinated during a vaccination campaign in Kogi State

What is a denominator?

A denominator usually refers to the total estimated number of eligible individuals in a population or the total estimated number of people in a target population3, 4. When delivering immunization services, health personnel develop micro plans to ensure that immunization services reach every community5. Micro-plans are used to identify priority communities, determine denominators/ eligible individuals, identify barriers and develop work plans for deploying solutions to those barriers6. Denominators are essential during the microplanning process to make sure that eligible people are not left out.  If health workers and administrators are unaware of a community’s existence, that community may be left out of micro-plans, denying eligible children the vaccines that they need. This will, in turn, reduce herd immunity in the state and eventually in the country, even though high immunization coverage rates are recorded.

An ongoing microplanning activity

For the past decade, eHealth Africa has worked with partners to support the National Program on Immunization and increasing the capacity of health systems to deliver quality health services, especially in underserved communities. eHA designs and deploys data-driven solutions and interventions that leverage Geographic Information Systems (GIS) technology, to identify and map settlements within the remotest communities, so that health workers can develop accurate, comprehensive micro-plans, to better plan and monitor health interventions.

A Data Collector collecting settlement data in Bauchi State

Through the Vaccinator Tracking Systems (VTS) project, we track the movement of vaccinators during SIAs to identify missed settlements and ensure that these settlements and their target population are reached, achieving a wider immunization coverage. Having mapped all the 36 states of Nigeria through the Geo-Referenced Infrastructure and Demographic Data for Development (GRID3) project, we provide up to date maps to states based on an accurate database of settlements and communities in  Nigeria, enabling our partner states to plan more efficiently. 

Case Study: Ganjuwa Local Government Area in Bauchi State

The Bauchi state master list of settlements contains 1,134 settlements for Ganjuwa Local Government Area (LGA). The planning for all interventions and projects in the state is based on this number. However, the eHealth Africa geodatabase has a list of 2,817 settlements for the same LGA, implying that almost 60% of the settlements in the LGA are left out during the microplanning process and consequently, during polio campaigns. Whenever eHA conducted the vaccinator tracking exercise based on the list on our geodatabase, the LGA perpetually fell below the target coverage rates.

To address this, eHA planned and conducted a “Hamlet Buster” activity to identify and rename the missed settlements in Ganjuwa LGA, in December 2019. The LGA had 2,051 machine-named settlements according to our geodatabase, the highest ever recorded in Nigeria.  Machine-named settlements occur when geospatial data collection tools pick up on features that are indicative of hamlet areas or small settlement areas. During a hamlet buster activity, field data collectors trace and visit these settlements using their geocoordinates, determine their name and accurate boundaries, and update them on the geodatabase. 

At the end of the hamlet buster activity in Ganjuwa, 1984 0f 2051 machine-named settlements were visited and renamed. This data will help to achieve the following in Bauchi State:

• Improve healthcare provision planning and Monitoring by updating the existing micro plans

• Harmonize the LGA/State master list of settlements with eHA’s geodatabase list

• Create more accurate health facility catchment area maps and targets for Routine Immunization and other interventions

“This work will help the state to achieve great milestones in health delivery because the data will not only be used for immunization but for other programs. It will make our planning for future activities easier and more realistic. The state is very grateful to eHealth Africa for this because we now have an authentic microplan. eHealth Africa also helped us to transit from paper-based to digital micro plans.”

— Bakoji Ahmed State Immunization Officer, Bauchi State.

Modelling Disease Surveillance Systems that work in Chad and Niger

By Tope Falodun and Emerald Awa-Agwu

Participants in Maradi, Niger after the training

Functional disease surveillance systems provide data that can be analyzed to yield insight for planning, project execution, monitoring, and evaluation of public health interventions. For a priority disease like Polio, surveillance systems are important because they monitor the burden of the disease and alert health systems of any increase in the occurrence of the disease in any location of implementation, ahead of time.

A key element that is often missing in disease surveillance systems is intersectoral action. In the past, the responsibility of finding, investigating, reporting and monitoring AFP cases rested solely on the disease surveillance officers (DSOs). This resulted in incomplete data because the DSOs could not cover every single community, and also manual errors as DSOs had to enter reports using paper-based tools.  Recognizing this, eHealth Africa (eHA) partnered with the World Health Organization (WHO), Novel-T, the Bill & Melinda Gates Foundation (BMGF) and the Ministries of Health in eight countries including Chad and Niger to develop the Auto- Visual AFP Detection and Reporting (AVADAR) system for improving AFP case identification and reporting. The goal of the project was to support health systems in polio-endemic and high-risk countries to find, report and investigate AFP cases using available, context-appropriate resources, in this case, community members. 

By partnering with local communities and enlisting members to serve as informants and investigators, some of the pressure on disease surveillance officers who performed all three functions of finding, investigating, reporting and monitoring suspected AFP cases were relieved. In addition, AVADAR infused digital data management and reporting innovations through the mobile application. With this, community informants report cases of suspected AFP via the AVADAR  mobile application. The investigators receive alerts of these reports on their mobile devices, locate the cases, investigate and collect stool samples for further laboratory tests in cases of true AFPs.  

In 2017, AVADAR was launched in 6 pilot districts in Chad and three pilot districts in Niger. By 2018, the project expanded to an additional three districts in both Chad and Niger. In total, eHA trained 849 and 509 community informants in Chad and Niger respectively. eHA also supported the training of 177 investigators by the WHO in Chad and 178 investigators in Niger. Within these periods, eHA supervised the activities of the informants, investigators, and technical officers, and also resolved technical issues relating to the mobile application, telecommunication, and network access on Android phones.

Chad 1st level supports going through pre-test during the transition training in Bokoro, Chad

“AVADAR has had a great impact on AFP surveillance, directly and disease surveillance as a whole by improving communication and information transfer.”

— Mbaielde Felix, Head of Abirebi Health Area, Bokoro District, Chad

After almost three years of supporting the health systems in Chad and Niger through AVADAR, it was evident that the model worked. eHA successfully handed over the continuation of the project in the pilot districts to the Ministries of Health and the World Health Organization in Chad and Niger. A total of 109 first and second line technical support officers in the two countries, were trained to continue to handle and resolve any technical issues that may arise. 

At eHA, we support health systems to effectively monitor and eradicate communicable diseases like polio by developing and supporting the development of creative surveillance methods and innovative data management solutions.

“AVADAR has allowed us to communicate with the informants, the district management team and the health delegation on the report of other diseases other than the AFP.”

— Abakar Mahamat Kalbassou, Head of Abgode Health Area, Bokoro District, Chad

The Importance of High-Quality AFP Surveillance Data in the Fight to Eradicate Polio

Polio is targeted for eradication because the presence of the virus anywhere means that children everywhere are at risk. The Global Polio Eradication Initiative (GPEI) focuses on strengthening Acute Flaccid Paralysis (AFP) surveillance worldwide to detect and respond to the poliovirus, to build herd immunity to protect the population and to halt the transmission of the virus. The data on the spread of AFP is invaluable especially for polio-endemic countries like Afghanistan, Pakistan, and Nigeria because it helps in determining whether they can finally be certified polio-free.

There are four steps involved in AFP surveillance and the Auto- Visual AFP Detection and Reporting (AVADAR) project responds to the first step—finding and reporting children with AFP—in eight priority countries in Africa. In many of these countries, disease surveillance and notification officers (DSNOs) at the health facilities are unable to actively find AFP cases for reasons ranging from difficulty in accessing settlements to security challenges. AVADAR trains community informants to search for and report the presence and/or absence of children with AFP in their community, using a mobile application. The application also has an embedded video that shows a child with AFP so that community informants can better recognize an AFP case. This reduces the burden on the DSNOs and allows them to focus on confirming if the case is truly AFP or not.

How AVADAR works

To ensure that AFP surveillance is conducted impactfully and that the AFP surveillance data collected is accurate, timely and of high quality, the GPEI defined five global indicators: Completeness of reporting, Completeness of case investigation, Completeness of follow-up, Sensitivity of surveillance and Laboratory performance.

Global Polio Eradication Initiative: AFP Surveillance indicators

AVADAR was designed by eHealth Africa, Novel-T, the World Health Organization (WHO) and other partners, to contribute to the achievement of the above targets. Below are the measures that have been put in place to ensure the collection and use of high-quality data to track and reports suspected AFP cases, and to inform decision making for polio eradication.

• Coverage: To decide where to site an AVADAR system, WHO carries out an assessment of the target country/districts to identify rural, hard-to-reach and underserved communities which are typically more predisposed to poliomyelitis. The AVADAR system, equipped with geospatial tracking capabilities is then deployed to community informants/ AFP reporters. This unique feature of the application helps to validate the location of the suspected AFP case, independent of the reporter.  

• Reporting: The AVADAR application allows informants to deliver reports anywhere and anytime in order to prevent data loss and to ensure near real-time, accurate reporting.  The app is designed to be used by people with basic literacy levels and is available in eighteen local African languages for ease of understanding. A report is better able to provide insight and enhance planning or decision making when it is timely. One of the key weekly metrics captured on the AVADAR dashboard is the number of complete results that were submitted as at when due, thus ensuring that all informants are actively engaged. Informants are expected to look out for and report cases of children aged 15 years and below, who have any form of physical deformity on the limbs or arms. In the event that no AFP case has been sighted within a week, the informant must send a ‘no report’, to validate his presence on the system.  

  AVADAR has improved the rate of AFP reporting compared to the traditional system of AFP reporting. For example, between June 2017 and June 2018 in the Lake Chad Basin countries(Chad, Niger, Nigeria, and Cameroon), the AVADAR system recorded 589 supsected cases against the 213 cases recorded by the traditional AFP Surveillance system.

• Verification: Paralysis in children can be caused by several agents including the Poliovirus. After the community informants submit their reports of suspected AFP cases, trained health workers carry out further investigations to confirm if they are true AFP cases. The WHO has designated laboratories all over target countries that are certified to test fecal samples and isolate the poliovirus. AVADAR weekly reports show how many suspected AFP cases were reported, how many were tested and the number of cases confirmed to be true AFP cases. This sort of data measures the cost of a single confirmed AFP case, the prevalence and incidence of AFP in target areas, thus enhancing the quality of AFP surveillance data for decision making.

AVADAR dashboard

Having data on the spread of AFP in a geographic location helps with planning towards its containment. Since Poliomyelitis is mainly oral-fecally transmitted, sanitization and sensitization of the environment and inhabitants respectively can help reduce the spread of polio.  AFP data gathered across different locations has been used in making an informed decision on determining the number of health workers that can effectively manage its spread to neighboring communities. On the contrary, no data or false data could lead to health workers focusing their energy in wrong locations thereby risking the spread of polio and the extension of its existence.

Without reliable and accurate AFP surveillance data, true progress towards polio eradication cannot be measured. AVADAR’s impact in high-risk countries across Africa demonstrates how context-appropriate interventions and solutions can transform disease surveillance and emergency management systems.

“One of the most important features of the AVADAR system is the engagement of over a hundred community informants per county. They are trained and equipped for the first time to provide timely reports that can be accessed at all levels from the county to the national level and beyond, thereby allowing suspected cases to be investigated in an accurate and efficient way.”

— Dr Sylvester Maleghemi, WHO Polio Eradication Initiative Team Lead, South Sudan

International Translation Day Spotlight: AVADAR

By Adaeze Obiako

“If you talk to a man in a language he understands, that goes to his head. If you talk to him in his language, that goes to his heart.”

— Nelson Mandela

This year, the United Nations is celebrating “International Translation Day” for the first time. The celebration is an opportunity to pay tribute to language professionals, whose work plays an important role in bringing nations together, facilitating dialogue, fostering understanding and cooperation, and contributing to the development and strengthening of world peace and security.

For eHealth Africa (eHA), translation has been instrumental to the success of several projects, particularly the Auto-Visual AFP Detection and Reporting (AVADAR) project.

When AVADAR commenced in 2016, we knew it was a worthwhile intervention towards the eradication of polio in Nigeria; however, we could not have anticipated just how much of a positive impact it would end up having on the Acute Flaccid Paralysis (AFP) surveillance system across Africa. Between 2016 and 2018, AVADAR grew from a small pilot in two states in Nigeria to a full-fledged project across 8 West and Central African nations. Several factors contributed to the success and scale of the project, one of which was the educational AFP video embedded in the AVADAR mobile app used to train community informants on proper detection (and subsequent reporting to health authorities) of AFP cases within their communities.

This is where language came in.

The project management team, made up of the World Health Organization (WHO), country Ministries of Health, the Bill and Melinda Gates Foundation, Novel-T, and eHA, knew early on that the key to ensuring accurate AFP detection and proper use of the AVADAR app for case reporting lay with developing a sense of connectedness and trust between all stakeholders (from project implementers to health workers to community informants) through the breakdown of language barriers.

Part of the pre-implementation phase in each country included research into what languages were spoken by indigenes using the AVADAR app and the AFP video, and the entire app was translated into each applicable language. Below is an example of the AFP video translated into Hausa, a local language commonly spoken in northern Nigeria, Niger, Chad, Cameroon and the Central African Republic.

In addition to the AFP video and app being translated into multiple languages, the training facilitators (who train informants on how to use the app) and field officers (who provide weekly phone troubleshooting support to informants) were all indigenes of the implementing regions and fluent in the local languages to ensure ease of communication and understanding for the AVADAR informants.

As AVADAR continues operation across Africa, it is clear that we have the power of translation to thank for bridging the gap and allowing thousands of community members and health workers across different African nations to support the fight against polio. At this rate, it won't be too long before polio, like smallpox, is considered a public health issue of the "past".